Filing Fee $20.00 DOMESTIC LIMITED LIABILITY COMPANY STATE OF MAINE Deputy Secretary of State STATEMENT OF WITHDRAWAL OF MEMBER A True Copy When Attested By Signature ______________________________________ Deputy Secretary of State (Name of Limited Liability Company) Pursuant to 31 MRSA §694, the undersigned member OR limited liability company executes and delivers for filing this statement of withdrawal of member: The following member has withdrawn from the above-named limited liability company. ________________________________________________________________________ (type or print name) DATED __________________________ WITHDRAWING MEMBER ___________________________________________________ ____________________________________________________ (signature) (type or print name) The following may be completed by the limited liability company, if the withdrawing member did not sign.* MANAGER(S)/MEMBER(S)* ___________________________________________________ ____________________________________________________ (signature) (type or print name and capacity) Name of Entity __________________________________________________________________________________________________ By ________________________________________________ (authorized signature) ____________________________________________________ (type or print name and capacity) *Statement MUST be signed by (1) at least one manager OR (2) at least one member if the limited liability company is managed by the members OR (3) any duly authorized person. The execution of this certificate constitutes an oath or affirmation under the penalties of false swearing under Title 17-A, section 453. A statement of withdrawal of a member is an optional filing. It may be used to cut off the ability of a withdrawing member to bind the limited liability company, particularly in a member-managed limited liability company. SUBMIT COMPLETED FORMS TO: CORPORATE EXAMINING SECTION, SECRETARY OF STATE, 101 STATE HOUSE STATION, AUGUSTA, ME 04333-0101 FORM NO. MLLC-9A Rev. 4/16/2001 TEL. (207) 624-7752 American LegalNet, Inc. www.FormsWorkFlow.com